I do not wish to dispute the authors' conclusion as it appears clear that the insula, anterior cingulate, and medial prefrontal cortex, while "associated" with self-awareness (SA), do not sustain it "per se". The conclusion that patient R “... is a conscious, self-aware, and sentient human being despite the widespread destruction of [the above-mentioned regions]...” (p. 11) is based on a very strong methodology indeed, e.g., extensive objective testing of various SA dimensions. One possible explanation for the current findings is that “... SA is likely to emerge from distributed interactions among networks of brain regions that include the brainstem, thalamus, and posteromedial cortices” (p. 15).

I agree, but find it rather remarkable that another plausible explanation of the results is not even considered once: that the patient preserved his self-awareness because language, and by extension inner speech, are intact. Most testing either involved the administration of questionnaires (e.g., Big Five Inventory) or verbal answers to questions pertaining to the self (see Table 1), and the patient was observed making spontaneous verbal comments on numerous occasions (e.g., during the Tickle Test). With intact verbal abilities, it seems likely that R can engage in verbal self-reflection and describe to himself his current mood, goals, needs, behavior, etc. through inner speech (see DeSouza et al., 2008; Morin, 2005; Neuman & Nave, 2010; Werning, 2010)—in short, be SA despite the destruction of brain areas purported to play an important role in SA.

While it is known that some more basic (“core”) aspects of SA such as self-recognition and sense of agency do not require language (e.g., verbal labeling; Morin & Hamper, 2012; Sugiura, 2007), it is also documented that more refined (“extended”, “introspective”) manifestations of SA are associated with language, and more specifically, inner speech (Morin, 2011). To illustrate, (1) people mostly talk to themselves "about themselves" (Morin et al., 2011); (2) a significant positive correlation has repeatedly been observed between measures of self-focus frequency and use of inner speech (e.g., Schneider et al., 2005); (3) inner speech dysfunctions following brain damage produce SA deficits (Morin, 2009); and (4) an activation of the left inferior frontal gyrus (known to sustain inner speech use) is observed in a significant number of brain-imaging studies of SA (Morin & Hamper, 2012).

Thus, while the idea that the current observations presented by Philippi et al. may be explained in purely neurological terms (interactions between brainstem, thalamus, and posteromedial areas), I believe that another, more cognitive option (speech-for-self) is also conceivable and should have been raised.

References
DeSouza, M.L., DaSilveira, A., & Gomes, W.B. (2008). Verbalized inner speech and the expressiveness of self-consciousness. Qualitative Research in Psychology, 5, 154–170.

Morin, A. (2011). Self-awareness Part 2: Neuroanatomy and importance of inner speech. Social and Personality Psychology Compass, 2/12, 1004-1012.

Morin, A. (2009). Self-awareness deficits following loss of inner speech: Dr. Jill Bolte Taylor’s case study. Consciousness and Cognition, 18(2), 524-529.

Morin, A. (2005) Possible links between self-awareness and inner speech: Theoretical background, underlying mechanisms, and empirical evidence. Journal of Consciousness Studies, 12(4-5), 115-134.

Morin, A., & Hamper, B. (2012). Self-reflection and the inner voice: Activation of the left inferior frontal gyrus during perceptual and conceptual self-referential thinking. The Open Neuroimaging Journal, in press.

Morin, A., Uttl, B., & Hamper, B. (2011). Self-reported frequency, content, and functions of inner speech. Procedia-Social and Behavioral Journal, 30, 1714-1718.

Neuman, Y., & Nave, O. (2010). Why the brain needs language in order to be self-conscious. New Ideas in Psychology, 28, 37–48.

Schneider, J.F., Pospeschill, M., & Ranger, J. (2005). Self-consciousness as a mediator between self-talk and selfknowledge. Psychological Reports, 96, 387–396.

Sugiura M. (2007). Cortical Networks for Visual Self-Recognition. Plasma and Fusion Research, 2, S1005–S1005.

Werning, M. (2010). Descartes discarded? Introspective self-awareness and the problems of transparency and compositionality. Consciousness and Cognition, 19, 751–761.